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Analysis of various THA interventions for the treatment of end stage arthritis of the hip
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September 2014
Analysis of various THA interventions for the treatment of end stage arthritis of the hip
Study Type:Meta-analysis/Systematic Review
OE Level Evidence:1
Journal Level of Evidence:N/A
Total hip replacement for the treatment of end stage arthritis of the hip: a systematic review and meta-analysis
PLoS One. 2014 Jul 8;9(7):e99804Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
Results from 14 RCTs and 5 systematic reviews were reviewed and pooled to determine the effect various THA interventions had on the pain, disability, and function experienced by patients with end stage arthritis of the hip. Results from the analysis indicated that patients experienced significant postoperative THA improvements in Harris Hip scores between 6 months and 10 years, but that improvements did not differ between various impact types. Additionally, a reduced risk of implant dislocation following intervention was noted for patients treated with a larger femoral head size or cemented cups (compared to smaller femoral heads and cementless cups, respectively). Those who received cross linked cup liners experienced reduced femoral head penetration and revision when compared to conventional polyethylene liners. Analysis of femoral stem fixation methods and cup shell designs indicated that neither had a significant effect on implant survival rates.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
the National Institute for Health Research, Health Technology Assessment Programm
Conflicts:
None disclosed
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Introduction
4/4
Accessing Data
4/4
Analysing Data
4/4
Results
3/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
The enhancement of designs, fixation methods, sizes, and bearing surfaces of implants for total hip arthroplasty (THA) has produced substantial procedural options for healthcare professionals and orthopaedic surgeons. This variety of potential approaches to TKA warrants an investigation to determine the most optional combinations of THR implants and techniques. The goal of this this systematic review and meta-analysis was to evaluate the clinical effectiveness of different types of THA used for the treatment of end stage arthritis, and to attempt to determine which techniques/ interventions are the most effective.
What was the principal research question?
How effective are various THA interventions at improving the pain and disability experienced by patients with end stage arthritis of the hip?
Study Characteristics
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Data Source:
An electronic search of the databases: MEDLINE, MEDLINE In-Process, Embase, Science Citation Index, Cochrane Library (Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials), Current Controlled Trials, ClinicalTrials.gov, Database of Abstracts of Reviews of Effectiveness (DARE), and HTA databases was conducted from 2008 to December 2012.
Index Terms:
Index terms used were not provided within this report or its appendices.
Study Selection:
Authors of the study examined reports to ensure that all included studies were English language RCTs or systematic reviews comparing different types of primary THR. Populations within the studies had to include patients with end stage hip arthritis (who had failed non-surgical intervention). Studies had to be comparing the composition/material, design, bearing surface, fixation method, or size of components. Studies with a population size <100 were excluded to avoid evidence with inconclusive findings.
Data Extraction:
Two independent reviewers extracted all outcomes. Discrepancies were resolved by a third reviewer. Primary outcomes extracted were: measures of hip functions and symptoms (HHS, Oxford Hip, WOMAC), mortality and causes, risk of revision, and femoral head penetration rate. Secondary outcomes extracted were: Validated clinical/functional measures (McMaster-Toronto Arthritis patient Preference Disability Questionnaire (MACTAR), Merle D’Aubigne Postel, UCLA score, health related quality of life, and peri/post procedural complications. Study characteristics, demographic information, and intervention/comparator types were also extracted.
Data Synthesis:
Pooling of studies was based on the degree of similarity in the methodological and clinical characteristics. Post-treatment mean difference (MD) for continuous outcomes and risk ratios (RR) for binary outcomes were pooled using a random-effects-model. Dichotomous outcomes with low event rates were pooled as RR using Matel-Haenszel (MH) fixed effect models. Dichotomous outcomes for studies with very low event rates (<5.0%) or zero events in one of the treatment arms were pooled as odds ratios (OR) using the Peto fixed effect model. Heterogeneity was assessed using the I-squared statistic.
What were the important findings?
- Searches by the authors identified 1,523 unique records, of which, 14 RCTs and 5 systematic reviews were included.
- 7 studies reported mean postoperative Harris Hip score between 6 months and 10 years. Results across the studies suggested that Harris Hip score improved in all interventions, but did not improve by significantly greater amounts when comparing patients treated with cemented and cementless cup fixation, between XLPE and transitional polyethylene cup liners, cemented and cementless stem fixation, metal on metal and metal on XLPE femoral head articulations, or ceramic on ceramic and metal on XLPE head articulations (p>0.05 for all).
- No differences were apparent between patients treated with XLPE or traditional PE cup liners when comparing WOMAC or Short Form-12 scores (p>0.05).
- A reduced risk of implant dislocation with the use of cemented cups was noticed when comparing its results against cementless cups (OR: 0.34, 95% CI: 0.13 to 0.89). A similar finding was found in favour of larger femoral head sizes (36 mm vs. 28 mm).
- Three RCTs indicated that patients with XLPE cup liners experienced a reduction in femoral head penetration rate and risk of revision (RR: 0.18; 95% CI: 0.04 to 0.78) when compared to those who received conventional PE cup liners.
- Analysis indicated that Femoral stem fixation and cup shell design had no significant effect on implant survival rates (p>0.05)
- Patients who received ceramic on ceramic articulations experienced a reduced risk of osteolysis when compared to those treated with XLPE head articulations
What should I remember most?
Results from the systematic review and meta-analysis indicated that patients experienced significant postoperative THA improvements in Harris Hip scores at 6 months to 10 years, but that improvements did not differ between various impact types. A reduced risk of implant dislocation following intervention was noted for patients treated with a larger femoral head size or cemented cups (compared to smaller femoral heads and cementless cups, respectively). Those who received cross linked cup liners experienced reduced femoral head penetration and revision when compared to conventional polyethylene liners. Analysis of femoral stem fixation methods and cup shell designs indicated that neither had a significant effect on implant survival rates.
How will this affect the care of my patients?
The majority of evidence obtained in this systematic review and meta-analysis was inconclusive due to poor reporting, missing data, or uncertain treatment estimates. The findings warrant cautious interpretation given the potential risk of bias, methodological limitations (small sample size, low event counts, short follow-up), and weak reporting of some studies included in this review. Long-term, detailed, RCTs on the topics included in this report are needed for more definitive conclusions.
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